Provider Demographics
NPI:1164119194
Name:OKERBLOM, WILLIAM C (DO (2023))
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:OKERBLOM
Suffix:
Gender:M
Credentials:DO (2023)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 COUNTRY HILL RD
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9626
Mailing Address - Country:US
Mailing Address - Phone:805-825-5524
Mailing Address - Fax:
Practice Address - Street 1:31700 TEMECULA PKWY
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-5896
Practice Address - Country:US
Practice Address - Phone:805-825-5524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program